Journal of Dentistry 88 (2019) 103171

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Journal of Dentistry
journal homepage: www.elsevier.com/locate/jdent

Effects of restoring SDF-treated and untreated dentine caries lesions on T

parental satisfaction and oral health related quality of life of preschool
children
Meng Jiang, May Chun Mei Wong, Chun Hung Chu, Linlu Dai, Edward Chin Man Lo⁎
Faculty of Dentistry, The University of Hong Kong, Hong Kong, China

ARTICLE INFO ABSTRACT

Keywords: Objectives: To find out the effects of placement of atraumatic restorative treatment (ART) restorations on par-
Atraumatic restorative treatment ental satisfaction and oral health related quality of life (OHRQoL) of preschool children with SDF-treated or
Silver diamine fluoride untreated dentine caries lesions.
Parental satisfaction Methods: In a randomized controlled trial conducted in Hong Kong, preschool children who had cavitated
Oral health related quality of life
dentine caries lesions were randomly assigned to receive application of silver diamine fluoride (SDF) solution or
Dental caries
placebo (tonic water) on their caries lesions 10 weeks before receiving ART restorations. Parents were asked to
Preschool children
rate their satisfaction with their child’s teeth using a 5-point scale (5 = very satisfied, 1 = very dissatisfied)
before and six months after the restorative treatment. Besides, the Chinese version of Early Childhood Oral
Health Impact Scale (C-ECOHIS) was used to assess the children’s OHRQoL.
Results: A total of 194 children participated in this study, with 101 and 93 children receiving SDF and placebo
application before ART restorations, respectively. There was no significant difference in parental satisfaction and
C-ECOHIS score between the SDF and placebo groups at baseline. At the 6-month follow-up, the mean parental
satisfaction score regarding their child’s dental health status increased significantly (p < 0.001) from 2.2 ± 0.7
to 2.8 ± 1.0 in the SDF group and from 2.3 ± 0.8 to 2.7 ± 0.9 in the placebo group. However, no significant
changes (p > 0.05) in C-ECOHIS scores were found in either of the two groups after ART restoration placement.
Conclusions: Placement of ART restorations can improve parental satisfaction with the health and appearance of
their child’s teeth but has no significant effect on the OHRQoL.
Clinical significance: This study provides valuable information about the effects of ART restoration placement on
SDF-treated or untreated dentine caries lesions regarding parental satisfaction and OHRQoL of preschool chil-
dren.

1. Introduction through topical applications of fluorides directly on the lesion without

Dental caries of young children is common in both developing and
industrialized countries [1]. In Hong Kong, the prevalence of dental
caries among 5-year-old children is around 50% [2]. The decay process
not only causes destruction of the dental tissues but can also cause
infection and pain in the young children. The adverse effects of dental
caries may impact on both children and their families, including sig-
nificant health, social and economic consequences [3].
Management of dental caries in children involves both prevention
and treatment of the disease. Both non-restorative and restorative ap-
proaches can be used in the treatment of carious lesion into dentine
[4,5]. A non-invasive and non-restorative approach is to halt the caries
process and convert an active carious lesion into an inactive one
removal of any dental tissues. An inactive (arrested) dentine caries le-
sion usually is hard on gentle probing and does not cause symptoms [4].
Results from randomized clinical trials show that annual or semi-annual
application of silver diamine fluoride (SDF) solution is effective in ar-
resting dentine caries in young children [6–8]. However, a common
outcome of SDF application is deposition of black stain on the arrested
caries lesions which may cause aesthetic concerns of both the children
and their parents [9].
Atraumatic restorative treatment (ART), in alignment with the
minimal invasive philosophy of dental caries management, is a patient-
friendly treatment for young children. The ART procedure involves
removal of soft carious dental tissues using hand instruments without
giving local anesthesia. An adhesive restorative dental material is then

⁎
Corresponding author at: 3F, Dental Public Health, The Prince Philip Dental Hospital, 34 Hospital Road, Sai Ying Pun, Hong Kong, China.
E-mail address: edward-lo@hku.hk (E.C.M. Lo).

https://doi.org/10.1016/j.jdent.2019.07.009
Received 10 April 2019; Received in revised form 10 June 2019; Accepted 14 July 2019
0300-5712/ © 2019 Elsevier Ltd. All rights reserved.
M. Jiang, et al. Journal of Dentistry 88 (2019) 103171

used to fill up the prepared cavity [10]. Usually a high viscosity glass
ionomer cement which is a tooth-coloured chemical-cured material is
used in a field setting. Results of a recent systematic review show that
the ART restorations placed in primary molars have a similar survival
rate compared to conventional treatment [11].
Although use of clinical parameters is important in assessing peo-
ple’s oral health condition, recently psycho-social influences on patients
are attracting more attention. Therefore, besides clinical parameters, it
is necessary to have patient-based assessment tools to evaluate oral
health impacts. Oral health related quality of life (OHRQoL) has been
defined as a multidimensional concept which includes a subjective
evaluation of the individual’s oral health, functional well-being, emo-
tional well-being and sense of self [12]. In measuring the OHRQoL of
children, it is generally believed that preschool children are too young
to be capable of abstract thinking which underlies perceptions of the
impacts of health and diseases, while the parents and caregivers who
are responsible and making decisions for their child’s oral health would
be in a better position to report the physical and psychological negative
impacts of their child’s oral health on the child and the whole family
[13]. So most of the child OHRQoL measurement tools currently
available, such as ECOHIS, Michigan−OHRQoL, OH-ECQOL, were de-
veloped for parents to complete [14]. Among these tools, Early Child-
hood Oral Health Impact Scale (ECOHIS) is the most commonly used
and was developed to measure OHRQoL of preschool children (younger
than 5 years old) [13]. The ECOHIS presents with good reliability, re-
sponsiveness and interpretability. Meanwhile, it is the only tool that has
been culturally adapted and translated in 14 languages, including the Fig. 1. Flow diagram of the study activities.
Chinese version ECOHIS (C-ECOHIS) [15].
Despite the high effectiveness of SDF application in treating active
at baseline. The minimum sample size was 152 in total.
caries in children, the black stain on the SDF-treated lesions may cause
patient and parental dissatisfaction, and affect their OHRQoL. A
method to improve the esthetics of the decayed teeth is to place a tooth- 2.2. Subject recruitment and group allocation
colour restoration to cover the stained cavity. The shape of the decayed
tooth can also be restored in the process to further enhance the overall Children attending grade 1 or 2 in nine kindergartens in Kong Hong
dental appearance. However, information on how effective is the pla- were offered a free dental examination in the kindergarten. These
cement of ART restorations in achieving the patient’s desired outcome kindergartens were chosen from the large (enrolment > 100) kinder-
is lacking. In this study, we aimed to find out the changes in parental gartens in different districts in Hong Kong so as to increase the gen-
satisfaction and OHRQoL of preschool children after ART treatment on eralizability of the findings. An invitation letter with information on the
untreated and SDF-treated dentine caries lesions. purpose and procedures of the study was sent to the parents through the
kindergarten. Written consent was obtained from parents before any
2. Material and method clinical procedure. Children who were found to have dentine caries
lesions in primary teeth were invited to join the randomized controlled
This study was part of a randomized controlled trial conducted in clinical trial. Children with serious systemic disease/conditions and
kindergartens in Hong Kong. Ethical approval was obtained from the who were uncooperative during treatment were excluded. Seriously
Institutional Review Board of the University of Hong Kong (IRB re- decayed teeth with signs of pulpal pathology and caries lesions which
ference Number: UW17-180) and the trial was registered (clinical- were too small to be prepared into a cavity for a filling with hand in-
trials.gov #NCT03657862). The flow of activities in the study is shown struments were also excluded.
in Fig. 1. The recruited children were randomly allocated into two groups
(SDF and placebo groups) using computer-generated random numbers.
2.1. Sample size calculation The group allocation was conducted by an independent dental assistant.
Participant children, their parents and the clinical examiners were
Sample size calculation was based on the primary outcome of the blinded to the children’s group allocation.
randomized controlled clinical trial, which was to investigated the
success of ART restorations in the untreated and SDF-treated caries 2.3. Interventions
lesions. An absolute difference of 10% in the success rate of restorations
was regarded as clinically significant. In this non-inferior clinical trial, The study interventions were conducted in the kindergartens
using one-tailed test with statistical significance set at 2.5% and a without the presence of the children’s parents. The clinical procedures
power of 80%, the calculated minimal number of restorations needed in were carried out with the children in a supine position lying on a table
each group was 139. Since more than one caries lesion can be found in or a bed. A disposable dental mirror attached to a handle with a LED
one child’s mouth, the clustering effect on sample size was considered. light at the tip was used as an intraoral light source during the clinical
It was anticipated that the number of decayed teeth included per study examination and treatment.
child was 2.5. A design effect of 1.15 was calculated, using an assumed For the children in the SDF group, a 38% SDF solution (Saforide,
intra-class correlation roh of 0.1. Thus, the necessary sample size was Toyo Seiyaku Kasei Co., Osaka, Japan) was applied onto all the caries
increased to 160. Furthermore, to compensate for a possible drop-out lesions in their primary teeth using micro-brushes with isolation of
rate of 15%, the sample size was increased to 188 restorations per teeth by cotton rolls. For the children in the placebo group, tonic water
group. Therefore, at least 76 children in each group should be recruited was applied in the same way. The children were then instructed not to

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M. Jiang, et al. Journal of Dentistry 88 (2019) 103171

eat or drink for at least half an hour after the application. groups were compared using chi-square test. The changes in parental
Ten weeks after the application of SDF solution or placebo, ART satisfaction and C-ECOHIS scores were calculated by subtracting the
restorations were provided to the study children in the kindergarten. baseline score from the 6-month follow-up score. Due to the non-
The included caries lesions were restored following the standard ART normal distribution of the scores, Wilcoxon Signed Ranks test (a non-
procedures with the use of hand instruments [10]. No local anesthesia parametric test) was used to compare the distribution of the baseline
was given. The dental restorative material used was a hand-mix high- and 6-month follow-up parental satisfaction and C-ECOHIS scores. The
strength chemical-cured glass ionomer (Ketac-molar, 3 M ESPE, Ger- Mann-Whitney test was adopted to compare parental satisfaction and C-
many). Isolation of the operating site was achieved with cotton rolls. ECOHIS scores of the SDF and placebo groups. The value of standar-
dized effect size (ES) was calculated by dividing the change in score by
2.4. Data collection the standard deviation of baseline scores [17]. An ES value ≤0.2 was
interpreted as having a small effect while ES values 0.3-0.7 and ≥0.8
At baseline, just before ART restoration placement (10 weeks after were regarded as having a moderate and a large effect, respectively
SDF or placebo application), children were clinically examined by two [18]. The statistical significance level for all tests was set at 5%.
trained dentists using disposable dental mirror attached to a handle
with an intra-oral LED light and a ball-ended probe. The status of each
3. Results
tooth was recorded and dental caries was diagnosed at the cavitation
level according to the criteria recommended by the World Health
A total of 194 children, aged 3–4 years, participated in this clinical
Organization [16]. Meanwhile, whether there was stain on any of the
trial. There were 101 children in the SDF group and 93 children in the
anterior teeth (canine to canine) was recorded as either “yes” or “no”.
placebo group. At baseline, 191 (98.5%) questionnaires were collected.
Six months after placement of the ART restorations, the study children
One questionnaire was excluded from C-ECOHIS analysis because more
were clinically examined again to assess the stain status of their ante-
than 40% of the C-ECOHIS questions were unanswered. Three ques-
rior teeth.
tionnaires were input with mode value in one item in the CIS. At the 6-
At baseline, parents were asked to complete a questionnaire. The
month follow-up, 193 (99.5%) questionnaires were collected. Two
questionnaire consisted of three parts: Part 1, general information, e.g.
questionnaires were excluded for C-ECOHIS analysis due to over 40% of
relationship with the child (mother, father, grandparents or others) and
questions being unanswered.
education level of parents; Part 2, parental satisfaction; and Part 3,
It can be seen from Table 1 that more boys than girls were recruited
children’s OHRQoL. Six months after placement of ART restorations (6-
in both SDF (57.4%) and placebo (61.3%) groups. Most (>80%) of
month follow-up), parents were asked to complete a follow-up ques-
questionnaires were answered by the child’s mother. More than 80% of
tionnaire which contained the same questions in Parts 2 and 3 of the
the parents had secondary school level education or above. No sig-
baseline questionnaire. The questionnaires were sent to the parents and
nificant difference in parents’ and children’s background was found
returned through the kindergartens.
between the two study groups (p > 0.05).
In the questionnaire, the parents were asked to rate their satisfac-
Table 2 displays the clinical features of the participant children. The
tion with four different aspects of their child’s teeth using a 5-point
mean ± SD decayed, missing and filled teeth (dmft) score of the par-
scale (5=very satisfied, 1=very dissatisfied). The four aspects were: 1)
ticipant children at baseline was 4.6 ± 3.4, with no significant
their child’s dental health status which mainly focused on tooth decay;
2) colour of their child’s anterior teeth, including stain on the teeth; 3)
Table 1
alignment of their child’s anterior teeth; and 4) overall appearance of Background of the participant parents and children.
their child’s teeth. Questionnaires with missing response in any of the
All participants SDF group Placebo group
above four questions were excluded from statistical analysis.
n = 194 n = 101 n = 93
The validated Chinese version of the Early Childhood Oral Health
Impact Scale (C-ECOHIS) [15] was used to assess the OHRQoL of the n % n % n %
participant children. The C-ECOHIS contained 13 items grouped into
two sections, child impact section (CIS) and family impact section (FIS). Gender of child
girl 79 40.7 43 42.6 36 38.7
Four domains were included in CIS: child symptom, function, psy- boy 115 59.3 58 57.4 57 61.3
chology and self-image/social interaction. For FIS, there were two do-
Relationship with child
mains: parent distress and family function. For each item, the parents mother 163 84.1 87 86.1 76 81.7
were asked to assess on a 5-point scale the negative impact of their father 26 13.4 11 10.9 15 16.1
child’s oral health on quality of life. Response categories were to record grandparents/others 5 2.5 3 3.0 2 2.2
how often an event had occurred: 0 = never; 1 = hardly ever; 2 = Mother’s education level
occasionally; 3 = often; 4 = very often; 5 = don’t know. All ‘don’t not completed secondary 33 17.0 17 16.8 16 17.2
know’ responses were recoded to missing. The total C-ECOHIS scores school
were derived by adding up the parents’ responses of all 13 items (total completed secondary 115 59.3 63 62.4 52 55.8
school
score can range from 0 to 52, with CIS and FIS ranging from 0 to 36 and tertiary, non-degree 25 12.9 11 10.9 14 15.1
0–16, respectively). Questionnaires with more than 40% of the C- course
ECOHIS items missing were discarded. Otherwise, the missing re- university degree 17 8.8 8 7.9 9 9.7
sponses and all ‘don’t know’ responses were imputed with the mode program
information missing 4 2.0 2 2.0 2 2.2
value so as to derive the total and domain scores. A higher C-ECOHIS
score indicated greater negative impact of oral health status on Father’s education level
not completed secondary 23 11.9 13 12.9 10 10.8
OHRQoL.
school
completed secondary 113 58.3 60 59.4 53 56.9
2.5. Statistical analysis school
tertiary, non-degree 32 16.5 17 16.8 15 16.1
Data were input into a computer using the software EpiData course
university degree 21 10.8 9 8.9 12 12.9
Manager 4.0 (EpiData Association, Denmark) with double check and
program
analyzed with the software SPSS (IBM SPSS statistics version 25, USA). information missing 5 2.5 2 2.0 3 3.3
Distribution of the characteristics of the participants in the two study

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M. Jiang, et al. Journal of Dentistry 88 (2019) 103171

Table 2
Clinical features of the participant children.
All participants SDF group Placebo group Children with Children without
(n = 194) (n = 101) (n = 93) anterior teeth anterior teeth restored
restored (n = 88)
(n = 106)

Mean (SD) dmft score 4.6 (3.4) 4.6 (3.6) 4.6 (3.3) 4.5 (3.7) 4.6 (3.2)
Mean (SD) no. of 2.6 (1.6) 2.7 (1.6) 2.6 (1.7) 3.0 (1.7) 2.2 (1.4)
restorations received
Mean (SD) no. of 1.1 (1.3) 1.2 (1.4) 1.0 (1.2) 2.0 (1.1) 0 0
restorations placed in
anterior teeth

BL 6m BL 6m BL 6m BL 6m BL 6m
% of children with stain 28.8 27.1 43.4* 28.4 13.0* 25.6 35.6 29.3 20.7 24.4

BL, baseline; 6 m, 6-month follow-up.

*
p < 0.001.

difference between the SDF (4.6 ± 3.6) and placebo (4.6 ± 3.3) groups
(p > 0.05). The mean number of restorations received per child was
2.6 ± 1.6. More than half (54.6%) of the participants received ART
restorations in their anterior teeth. At baseline, proportionally more
children in the SDF group had stain on their anterior teeth compared
with that in the placebo group (43.4% vs 13.0%, p < 0.001). At 6-
month follow-up, there was no significant difference in the proportion
of children having stain on their anterior teeth between the SDF and
placebo groups (p > 0.05).
At baseline, the mean ± SD parental satisfaction scores regarding
dental health status and colour of anterior teeth were 2.2 ± 0.8 and
2.6 ± 1.0, respectively (Table 3). There was no statistically significant
difference in the distribution of parental satisfaction scores between the
SDF and placebo groups (p > 0.05). Whether children having anterior
teeth restored or not, the distributions of parental satisfaction scores in
all four aspects had no statistically significant difference (p > 0.05).
The mean parental satisfaction scores regarding their child’s dental
health status and colour of anterior teeth increased significantly at 6-
month follow-up. A moderate ES was found in two aspects, dental
health status (ES = 0.6) and colour (ES = 0.3). However, only a small
effect (0.1) was observed in two aspects, namely ‘alignment’ and
‘overall tooth appearance’. At baseline, only 6% and 10% of the parents
in the SDF and placebo groups, respectively, gave a satisfaction score
greater than 3 regarding their child’s dental health status. At 6-month
follow-up, proportionally more parents in both SDF (38%) and placebo
(28%) groups were satisfied with their child’s dental health status. A
large ES (0.9) of parental satisfaction with their child’s dental health
status was observed in the SDF group. In the placebo group, a moderate
ES (0.5) was observed in the same aspect. Results of the Wilcoxon
Signed Ranks Test indicated that the parental satisfaction score of their
child’s anterior tooth colour at 6-month follow-up increased sig-
nificantly in the SDF group (p = 0.002), while no significant change
was found in the placebo group (p > 0.05). For the overall tooth ap-
pearance, parents whose child had anterior teeth restored gave sig-
nificantly higher score at follow-up (p = 0.034) while no significant
change was found among parents whose child did not receive any
anterior teeth restoration (p > 0.05).
Table 4 displays the frequency of C-ECOHIS response (%) of the two
study groups at baseline and 6-month follow-up. At baseline, 20.4% and
34.8% of the parents in the SDF and placebo groups had a zero C-
ECOHIS score. More than 70% of the parents in both two groups re-
ported that their child never or hardly ever had pain in teeth, mouth or
jaws. No significant change was found at the 6-month follow-up, with
about a quarter of parents still had a zero C-ECOHIS score and more
than 60% of the children never or hardly ever had dental pain. Fur-
thermore, the vast majority (>80%) of children seldom had ‘function’,
‘psychology’ or ‘self-image/social interaction’ problems related to their
oral health. As for the FIS, around one third of the parents reported
having parental distress, ‘being upset’ or ‘feeling guilty’, at least occa-
sionally and there was not much change at the 6-month follow-up.
The mean C-ECOHIS scores at baseline and 6-month follow-up are
shown in Table 5. No statistically significant changes in the mean total
C-ECOHIS, CIS and FIS scores were found between baseline and 6-
month follow-up (p > 0.05). Furthermore, results of Mann-Whitney
Test indicated no significant difference in the distribution of C-ECOHIS
scores between the SDF and placebo groups at both baseline and 6-
month follow-up (p > 0.05).
4. Discussion
As a noninvasive caries management method, results of clinical
studies show that SDF application is accepted by parents because of its
ease of application and pain free procedure [19,20]. Significant im-
provement in parental satisfaction with their child’s dental health 18

Table 3
Mean parental satisfaction scores at baseline and 6-month follow-up, and effect size (ES).
All participants SDF group placebo group Children with anterior teeth Children without anterior
(n = 190) (n = 98) (n = 92) restored teeth restored
(n = 103) (n = 87)

BL 6m ES BL 6m ES BL 6m ES BL 6m ES BL 6m ES

Dental health status 2.2 2.8*** 0.6 2.2 2.8*** 0.9 2.3 2.7*** 0.5 2.2 2.7*** 0.7 2.3 2.8*** 0.6
Color 2.6 2.9*** 0.3 2.6 2.9** 0.3 2.7 2.9 0.2 2.5 2.8** 0.3 2.8 3.0* 0.2
Alignment 3.2 3.3* 0.1 3.2 3.3 0.1 3.1 3.3 0.2 3.1 3.2 0.1 3.2 3.4 0.1
Overall appearance 3.1 3.2 0.1 3.0 3.2 0.2 3.2 3.3 0.1 3.0 3.2* 0.2 3.2 3.3 0.1

BL, baseline; 6 m, 6-month follow-up; ES, effect size.

***p < 0.001; **p < 0.01; *p < 0.05; p-value was derived by Wilcoxon Signed Ranks test to compare the parental satisfaction scores between baseline and 6-month
follow-up.

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M. Jiang, et al. Journal of Dentistry 88 (2019) 103171

Table 4
Frequency of C-ECOHIS response (%) at baseline and 6-month follow-up.
SDF group (n = 98) placebo group (n = 89)

Never or hardly ever Occasionally Often or very Often Never or hardly ever Occasionally Often or very Often

BL 6m BL 6m BL 6m BL 6m BL 6m BL 6m

Symptom
a) pain in the teeth, mouths or jaws? 71.4 72.4 25.5 25.5 3.1 2.0 75.3 62.9 20.2 33.7 4.5 3.4

Function
b) difficulty drinking beverages? 92.9 88.8 7.1 11.2 0.0 0.0 93.3 91.0 6.7 5.6 0.0 3.4
c) difficulty eating foods? 86.7 83.7 10.2 14.3 3.1 2.0 87.6 80.9 10.1 16.9 2.2 2.2
d) difficulty pronouncing any words? 84.7 82.7 9.2 16.3 6.1 1.0 88.8 91.0 6.7 6.7 4.5 2.2
e) missed school? 95.9 99.0 4.1 1.0 0.0 0.0 98.9 97.8 1.1 2.2 0.0 0.0

Psychology
f) trouble sleeping? 95.9 91.8 4.1 8.2 0.0 0.0 94.4 91.0 5.6 9.0 0.0 0.0
g) been irritable or frustrated? 93.9 93.9 6.1 6.1 0.0 0.0 92.1 91.0 5.6 7.9 2.2 1.1

Self-image/social interaction
h) avoided smiling or laughing? 92.9 91.8 6.1 7.1 1.0 1.0 94.4 94.4 4.5 5.6 1.1 0.0
i) avoided talking? 95.9 95.9 3.1 4.1 1.0 0.0 98.9 98.9 1.1 1.1 0.0 0.0

Parental distress
j) been upset? 70.4 71.4 23.5 23.5 6.1 5.1 74.2 68.5 22.5 24.7 3.3 6.7
k) felt guilty? 68.4 72.4 22.4 19.4 9.2 8.2 73.0 66.3 18.0 27.0 9.0 6.7

Family function
l) take hours or days off work? 95.9 93.9 3.1 6.1 1.0 0.0 92.1 88.8 7.9 11.2 0.0 0.0
m) affected the family's economic 92.9 89.8 6.1 10.2 1.0 0.0 88.8 87.6 10.1 10.1 1.1 2.2
situation?

BL, baseline; 6 m, 6-month follow-up.

No statistically significant difference was found between groups, and between BL and 6 m.

and 30 months after SDF application has also been reported [20]. De-
spite this, there are limitations in what can be achieved through ap-
plications of SDF. SDF treatment can arrest active caries and prevent
development of dental complications but probably does not improve
chewing function and dental appearance.
A black and hard surface of a caries lesion is a clinical sign in-
dicating that the progression of dental caries has been stopped [21], but
this may not be understood by lay persons. A blackened unrestored
cavity in a child’s tooth may still be a concern for the parents. They may
like to see that the cavity is filled with a tooth-colour material. In the
present study, parental satisfaction with their child’s dental health
status increased significantly after ART restoration placement in both
study groups and no matter whether there were restorations placed in
the child’s anterior teeth. At baseline, before the placement of ART
restorations, most of the parents were probably aware of their child’s
dental health problems and were generally dissatisfied (mean satisfac-
tion score <3) regardless whether their child’s decayed teeth had been
treated with SDF or not.
In this study, stain could be found on the anterior teeth of children
in both groups. As one of the outcomes of SDF application was staining
on the arrested caries lesion, the prevalence of stain was much higher in
the SDF group compared with the placebo group before placement of
ART restoration. Even without SDF application, some children in the
placebo group had stain on their anterior teeth. It is probably because of
the deposit of dietary chromogens and other substances on the tooth
surfaces. The actual mechanism of staining is not fully understood but it
is associated with poor oral hygiene and some dietary habits, e.g.
drinking tea, coffee, or cola [22]. After ART restoration placement, the
cavities with black stain caused by SDF application were restored and
covered by glass ionomer cement. The prevalence of stain dropped in
the SDF group with no significant difference compared with that in the
placebo group at the 6-month follow-up. Consequently, parental sa-
tisfaction with the colour of their child’s anterior teeth (including stain)
increased in the SDF group at 6-month follow-up.
Regarding satisfaction with the overall appearance of their child’s
teeth, parents whose child had anterior teeth restored reported sig-
nificantly increased satisfaction while the other parents did not. Very
likely, the parents were more sensitive about an improvement in the
appearance of their child’s anterior teeth compared to that in the pos-
terior teeth. However, no significant change in parental satisfaction
with the overall dental appearance of their child was found in either the
SDF or placebo group 6 months after the placement of ART restorations.
It is noted that many factors of the teeth, e.g. tooth colour, shape,
alignment and occlusal relationship, as well as individual perception of
aesthetics can affect parental satisfaction with overall dental appear-
ance. It is not surprising that provision of restorative treatment alone

Table 5
Mean (SD) of C-ECOHIS score at baseline and 6-month follow-up.
All participants SDF group Placebo group
(n = 187) (n = 98) (n = 89)

BL 6m BL 6m BL 6m

CIS 4.0 (4.6) 4.3 (4.9) 4.1 (4.6) 4.2 (4.6) 3.8 (4.6) 4.3 (5.1)
FIS 2.6 (2.9) 2.7 (2.9) 2.6 (2.7) 2.6 (2.7) 2.5 (3.1) 2.8 (3.1)
C-ECOHIS 6.5 (7.0) 7.0 (7.3) 6.8 (6.7) 6.9 (6.8) 6.3 (7.2) 7.1 (7.8)

BL, baseline; 6 m, 6-month follow-up; CIS, child impact section; FIS, family impact section.
No statistically significant difference was found between groups, and between BL and 6 m.

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M. Jiang, et al.
may not be sufficient to significantly improve the parents’ overall sa-
tisfaction.
Regarding the OHRQoL of the participant children in this study, it is
noted that the mean ECOHIS score at baseline is lower than those in
studies conducted in other countries [13,18,23–25], but similar to that
found in a survey conducted in Hong Kong [26]. One of the reasons is
that the source of study children was different. Participants in this study
were recruited from kindergartens while those in the studies conducted
in other countries were from dental clinics or hospitals. Children who
seek dental treatments probably have poor oral health. Thus, low level
of OHRQoL reported was due to the impacts from their oral health
problems. Besides, due to cultural differences, Chinese parents may
perceive less impact from their child’s dental problems compared to the
parents influenced by other cultures.
The clinical success of ART restorations has been reported in many
clinical studies [27], but information from patient-based assessment of
the impacts of ART restorations on physical, social and psychological
well-being is needed to supplement the clinical findings. A few studies
were conducted in this area but their results were not consistent. A
study conducted in Australia reported that the MID-ART approach im-
proved ECOHIS scores of children compared to standard care ap-
proaches [24]. However, in the present study, the OHRQoL of the study
children as measured by the ECOHIS did not change significantly after
placement of ART restorations, which is consistent with the findings of
a study conducted in Brazil [28]. This finding can be explained in
several ways. Firstly, the low C-ECOHIS score at baseline indicates a
low level of negative influences of oral health problems on the daily life
of the study children and their families. Thus, there was little room for
improvement in the children’s OHRQoL after receiving ART restora-
tions. Secondly, although ART as a minimally invasive caries treatment
might have caused some subtle changes in the OHRQoL of the study
children, these might not be perceived and reported by their parents. It
has been reported that there is an association between the respon-
siveness of the ECOHIS and the complexity of dental treatment received
by preschool children. A study found that children who received more
complicated dental treatment such as endodontic treatment and tooth
extraction had more changes in their ECOHIS score than those who
received non-operative treatment only [29]. In addition, a number of
studies found marked decrease in ECOHIS scores in the children after
they had received dental treatments under general anesthesia
[23,25,30,31]. Thirdly, in this study, the ART restorations were pro-
vided to the children in the kindergarten without the presence of their
parents. Without involving the parents, their perceived changes in the
OHRQoL of their child after receiving dental treatment may be different
from the situation where a dentist-child-parent relationship is estab-
lished [32].
The present study had a high response and retention rate, and
provides valuable information about the changes in OHRQoL of pre-
school children after receiving ART restorations. Nevertheless, limita-
tions of the present study should also be noted. The ART restorations in
this study were provided to Chinese preschool children in a kinder-
garten setting in Hong Kong, so the results may not be generalizable to
other ethnic populations or to preschool children receiving restorations
in a clinic setting. In addition, 6 months may not be long enough to fully
evaluate the impacts of ART restoration placement on children’s
OHRQoL. Long-term changes should be investigated in future studies.
Moreover, measurement tools of preschool children’s OHRQoL that
solely rely on parental report may not be able to fully reflect the ben-
efits of dental treatments because the parents may not perceive all the
impacts of oral health problems on their child.
Within the limitations of this study, it is concluded that placement
of ART restorations regardless whether the decayed teeth have pre-
viously received application of SDF solution or not can improve par-
ental satisfaction with their child’s dental health status. In addition,
placement of ART restorations on SDF-treated anterior primary teeth
can lead to higher parental satisfaction with the colour of their child’s
6
Journal of Dentistry 88 (2019) 103171
teeth. However, this minimal invasive restorative treatment has no
significant effect on the OHRQoL of preschool children.
Acknowledgment
The authors are thankful to Ms. Samantha KY Li for her advice on
the statistical analysis. This research was partly funded by the Research
Grants Council, Hong Kong (Grant No. 17120217).
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